MEDICARE: DR. CHARLES F MATTINGLY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14178	MO

General Provider Information

NPI Number	:	1467449892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES F MATTINGLY DDS

Provider Business Mailing Address
First Line	:	211 W BRIARWOOD LN
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-1607
Country	:	US
Telephone Number	:	573-445-7298
Fax Number	:

Provider Business Practice Location Address
First Line	:	409 VANDIVER DR
Second Line	:	BLDG 3 SUITE 102
City	:	COLUMBIA
State	:	MO
Zip	:	65202-3754
Country	:	US
Telephone Number	:	573-499-1699
Fax Number	:	573-442-7897

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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